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My Book

Archive for the 'Twilight of Expertise' Category

The New Yorker used to have a mini-department called The Clouded Crystal Ball: examples of bad predictions taken from “newsbreaks” — little bits of text used to fill a column. In an interview, a friend of mine named Margaret Meklin told of a different sort of clouded crystal ball:

My first job in the U.S. was passing out flyers for a fortune teller on Powell and Market in San Francisco. She did not trust her psychic powers enough to guess who was doing a truly good job (it was me!), so she would periodically hide in the tourist crowds to check if we were passing out flyers quickly and efficiently and to a sufficient number of passersby. She gave a higher pay rate to my co-worker, thinking that he was more productive, but she had no idea that he would simply toss a whole stack of flyers into a trash can when she wasn’t watching him.​

At the end of Fear of Food: A History of Why We Worry about What We Eat by Harvey Levenstein (2012), an historian at McMaster University, the author summarizes what he has learned:

During the course of writing this book, I have often been asked what lessons I personally draw from it. . . . The hubris of experts confidently telling us what to eat has often been well-nigh extraordinary. In 1921, for example, the consensus among the nation’s nutritional scientists was that they knew 90% of what there was to know about food and health.

Yeah. Two questions for an expert giving advice, especially apocalyptic advice (“You’ll die if you don’t . . . “): 1. What fraction of what there is to be known on your subject do you know? 2. May I quote you?

When I was a freshman in college, I went to hear a talk (off campus) about the chance of life elsewhere in the universe (or was it the galaxy?). The speaker multiplied a bunch of numbers together and came up with an estimate. “What’s the error in that estimate?” I asked. The speaker had no answer. He didn’t know. It’s essentially the same thing.

I recently came across two different people who, diagnosed with Crohn’s disease, repeated the standard line that it “has no known cure”. Really? Never? The people who said this were just repeating what they had been told. Unlike twenty or thirty years ago, however, it is easy to do one’s own research. The people who said this gave no indication they had done any research. Because Crohn’s is so unpleasant, their passivity was curious.

I knew that calling Crohn’s disease “incurable” was an overstatement because I had written about Reid Kimball, who had found a way to eliminate via diet essentially all the symptoms. For practical purposes, he was cured. (Reid objects to the word “cure”.) I knew he was hardly the only one. But what if I started from ignorance? How hard would it be to challenge the conventional “incurable” line?

Not hard at all. I googled “Crohn’s success” (without quotation marks in the search query). The top search result (titled “Crohn’s Disease: Success with Diet and Probiotics”) included this:

I learned of a pediatric gastroenterologist, Dr. J. Rainer Poley, who had conducted extensive studies on the effect of certain sugars and starches on people with intestinal diseases. My husband and I decided to take our daughter to see this doctor for another opinion. When we asked him if there was any other treatment she could try besides medications, he explained that at a recent medical conference in Europe, he had learned of success medical doctors were having with probiotics. He instructed our daughter to eat plain yogurt every day and to take a specific probiotic capsule called Culturelle® containing Lactobacillus GG [Gorbach and Goldin] twice daily. Based on Dr. Poley’s research, he wanted her to limit the consumption of concentrated sugars (specifically table sugar, technically known as sucrose). The intent of the sucrose-restricted diet was to starve the harmful bacteria by taking away their major food source. The yogurt and Lactobacillus GG would help replenish the “good” bacteria. Since it has been well documented that an overgrowth of bacteria is prevalently seen in people with Crohn’s disease, this treatment sounded like a plausible solution.

Our daughter, feeling drained from the effects of Crohn’s disease, felt motivated to try the doctor’s recommendations. . . . After about two weeks, she began to feel better in general. At the follow-up doctor’s appointment three months later, she had gained six pounds and her lab work was ALL NORMAL! . . . She continues to remain well [over 7 years later] with normal lab work and without clinical symptoms.

I asked Ms. Kalichman how others had fared with this treatment. She replied:

Periodically, I hear from others who have tried the treatment that my daughter does, and it seems that many have been helped a lot. Unfortunately they don’t always continue to keep in touch, so I don’t have any idea how many are totally well. Our daughter continues to be well as she has been for almost 9 years now…no meds and no clinical symptoms.

That took about 5 minutes, including emailing Kalichman. She referred me to a video about it.

Shortly before Obama took office, many American banks, including the largest ones, were given a huge amount of money by the Federal government (“bailed out”). Why? Because Secretary of the Treasury Henry Paulson, Chairman of the Federal Reserve Ben Bernanke and other economists (not necessarily independent of Paulson and Bernanke) predicted a second Great Depression if they weren’t. I didn’t believe Paulson et al. — their track records of prediction were terrible. They hadn’t foreseen the crisis. Why should I think they knew how to fix it? I believed their predictions of disaster were too confident.

The blood-curdling threats [now] being issued by Eurocrats should sound familiar to British readers. We went through precisely the same experience 20 years ago, when we were stuck with an over-valued exchange rate in the Exchange Rate Mechanism.

As in Greece, our leaders – all the main parties, the CBI, the TUC, the Bank of England – assured us that leaving the ERM would be disastrous. On September 11, 1992, John Major solemnly told us that withdrawal was ‘the soft option, the inflationary option, the devaluer’s option, a betrayal of our country’s future’.

Four days later, we left the system, and our recovery began immediately. Inflation, interest rates and unemployment started falling, and we enjoyed 15 years of unbroken growth

Michael Ellsberg has an excellent article about the American Dietetic Association’s attempts to make it illegal for anyone they haven’t approved to give nutritional advice. In this document, they are frank that this is their goal. After Ellsberg drew attention to it, it was taken down. I look forward to learning why it was taken down.

The Washington State chapter of the ADA, now called the Washington State Academy of Nutrition and Dietetics, is responsible for taking down the document. The organization has this mission statement:

Empowering the people of Washington to improve health with safe, effective and reliable food and nutrition information.

Our Vision: Optimize the health and well being of Washington State individuals through food & nutrition.

Our Mission: Empower members to be Washington State’s food and nutrition leaders.

Long ago, in the civil rights or suffrage movements, for example, empowerment meant removal of barriers. This organization preaches empowerment by creation of barriers. Their empowerment is someone else’s disempowerment.

The newly-released climate scientist emails (called Climategate 2.0) from University of East Anglia (Phil Jones) and elsewhere (Michael Mann and others) show that top climate scientists agree with me. Like me (see my posts on global warming), they think the evidence that humans have caused dangerous global warming is weaker than claimed. Unfortunately for the rest of us, they kept their doubts to themselves: “I just refused to give an exclusive interview to SPIEGEL because I will not cause damage for climate science.”

This is a big reason I have found self-experimentation useful. It showed me that experts exaggerate, that they overstate their certainty. At first I was shocked. My first useful self-experimental results were about acne. I found that one of the two drugs my dermatologist had prescribed didn’t work. He hadn’t said This might not work. He didn’t try to find out if it worked. He appeared surprised (and said “why did you do that?”) when I told him it didn’t work. Another useful self-experimental result was breakfast caused me to wake up too early. Breakfast is widely praised by dieticians (“the most important meal of the day”). I have never heard a dietician say It could hurt your sleep or even a modest There’s a lot we don’t know. My discoveries about morning faces and mood are utterly different than what psychiatrists and psychotherapists say about depression.

As anyone paying attention has noticed, it isn’t just climate scientists, doctors, dieticians, psychiatrists, and psychotherapists. How can you tell when an expert is exaggerating? His lips move. There are two types of journalism: 1. Trusts experts. 2. Doesn’t trust experts. I suggest using colored headlines to make them easy to distinguish: red = trusts experts, green = doesn’t trust experts.

Imagine if, to get the news, you had to go somewhere and have it read to you! What a joke. From an article in the Washington Monthly about on-line education:

If Solvig needed any further proof that her online education was the real deal, she found it when her daughter came home from a local community college one day, complaining about her math course. When Solvig looked at the course materials, she realized that her daughter was using exactly the same learning modules that she was using at StraighterLine . . . The only difference was that her daughter was paying a lot more for them, and could only take them on the collegeâ€™s schedule. And while she had a professor, he wasn’t doing much teaching. “He just stands there,” Solvig’s daughter said.

The excellent article misses something big, however:

A lot of silly, too-expensive things “vainglorious building projects, money-sucking sports programs, tenured professors who contribute little in the way of teaching or research” will fade from memory, and won’t be missed.

A friend of mine, who lives in Shanghai, has a 3-year-old son. She gets all her parenting advice from the Internet. This would be uninteresting except that her mother lives with her. (So does her husband’s mother.) On a daily basis, in other words, whatever her mom thinks about how kids should be raised is being ignored. My guess is that her mom actually likes the situation because it removes a source of conflict. But I didn’t dare ask.

Atul Gawande might be the best medical writer ever. He is the best medical writer at The New Yorker, at least, and the best one I’ve ever read. He consistently writes clearly, thoughtfully, and originally about the big issues in medicine. That is why his recent article about health care costs (my comment here) and his graduation speech at the Univesity of Chicago are so telling. And not in a good way, I’m afraid.

The graduation speech starts off with an excellent story:

The program, however, had itself become starvedâ€”of money. It couldnâ€™t afford the usual approach. The Sternins had to find different solutions with the resources at hand.

So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished childrenâ€”who among them had demonstrated what Jerry Sternin termed a â€œpositive devianceâ€ from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those childrenâ€™s mothers were breaking with the locally accepted wisdom in all sorts of waysâ€”feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the childrenâ€™s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.

Bill Gates, Jeffrey Sachs, are you listening?Â Gawande goes on to say that to improve medicine, there needs to be the same sort of study of “positive deviants”. Here is his first example:

I recently heard from one such positive deviant. He is a physician here in Chicago. Heâ€™d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patientsâ€”to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.

No kidding. The contrast between mothers who figure out creative iconoclastic new ways to feed children on tiny amounts of money and a doctor who merely refuses to be a scumbag could hardly be greater. But Gawande uses the same term (“positive deviant”) for both! This is the depth to which a writer and thinker of Gawande’s stature has to descend, given the straitjacket of how he thinks about medicine. Gawande thinks that doctors will improve medicine. He’s wrong. Just as farmers didn’t invent tractors — nor any of the big improvements in farming — neither will doctors be responsible for any big improvements in American health. The big improvements will come from outside. I’m sure they will involve both (a) advances in prevention and (b) patients taking charge of their care.

When these innovations happen, where will doctors be? Helping spread them or defending the status quo? That’s what Gawande should be writing about. One big advance in patients taking charge was home blood glucose testing. It came from an engineer named Richard Bernstein. Best thing for diabetics since the discovery of insulin. Doctors opposed it. When I invented the Shangri-La Diet, and lost 30 pounds, my doctor didn’t ask how I lost all that weight. Not one question. Like all doctors, he had many fat patients; the notion that I, a mere patient, could know something that would help his other patients didn’t cross his mind. When I was a grad student I did acne experiments on myself that revealed that antibiotics (hugely prescribed for acne) didn’t work. My dermatologist appeared irritated that I had figured this out. That’s a little glimpse of how doctors may react to outside innovation involving patients taking charge. Of course doctors, like dentists, cannot do good prevention research.

If Gawande took the first story he told to heart, he might realize it is saying that the improvements to health care won’t come from doctors, just as the improvements to the health of those village children didn’t come from experts. As I said earlier, doing my best to channel Jane Jacobs, a reasonable health care policy would empower those who benefit from change. That’s what the village nutrition program did. It empowered mothers who were innovating.

A specialist light treatment for psoriasis is just as effective and safe when given at home as in hospital, say Dutch researchers. Phototherapy using UVB light is rarely used in the UK because of limited availability and the number of hospital visits required. But a study of 200 patients found the same results with home treatment. . . .

One reason that the treatment is usually done in hospital is because most dermatologists believe that home phototherapy is inferior and that it carries more risks.In the latest study, patients with psoriasis from 14 hospital dermatology departments were randomly assigned to receive either home UVB phototherapy or hospital-based treatment. Home treatment was equivalent to hospital therapy both in terms of safety and the effectiveness of clearing the condition. And those treated at home reported a significantly lower burden of treatment and were more satisfied.

There was a time when blood-glucose testing (for diabetes) was only done in laboratories, with blood drawn in doctors’ offices or hospitals.

Long ago the RAND Corporation ran an experiment that found that additional medical spending provided no additional health benefit (except in a few cases). People who didn’t like the implication that ordinary medical care was at least partly worthless could say that it was only at the margin that the benefits stopped. This was unlikely but possible. Now a non-experimental study has found essentially the same thing:

To that end, Orszag has become intrigued by the work of Mitchell Seltzer, a hospital consultant in central New Jersey. Seltzer has collected large amounts of data from his clients on how various doctors treat patients, and his numbers present a very similar picture to the regional data. Seltzer told me that big-spending doctors typically explain their treatment by insisting they have sicker patients than their colleagues. In response he has made charts breaking down the costs of care into thin diagnostic categories, like “respiratory-system diagnosis with ventilator support, severity: 4,” in order to compare doctors who were treating the same ailment. The charts make the point clearly. Doctors who spent more â€” on extra tests or high-tech treatments, for instance â€” didn’t get better results than their more conservative colleagues. In many cases, patients of the aggressive doctors stay sicker longer and die sooner because of the risks that come with invasive care.

Perhaps the doctors who ordered the high-tech treatments, when questioned about their efficacy, would have responded as my surgeon did to a similar question about the surgery she recommended (and would make thousands of dollars from): The studies are easy to find, just use Google. (There were no studies.)

It’s like the RAND study: Defenders of doctors will say that some of them didn’t know what they were doing but the rest did. But that’s the most doctor-friendly interpretation. A more realistic interpretation is that a large fraction of the profession doesn’t care much about evidence. In everyday life, evidence is called feedback. If you are driving and you don’t pay attention to and fix small deviations from the middle of the road, eventually you crash. You don’t need a double-blind clinical trial not to crash your car — a lesson the average doctor, the average medical school professor, and the average Evidence-Based-Medicine advocate haven’t learned.

The wearer adjusts a dial on the syringe to add or reduce amount of fluid in the membrane, thus changing the power of the lens. When the wearer is happy with the strength of each lens the membrane is sealed by twisting a small screw, and the syringes removed. The principle is so simple, the team has discovered, that with very little guidance people are perfectly capable of creating glasses to their own prescription.

Speaking of not needing opticians and making glasses more affordable, a year ago I discovered by accident something extremely useful: Wearing one contact lens is better than wearing two.

Wearing just one contact lens, I get good distance vision from the lensed eye and and good close-up vision from the unlensed eye. Wearing two contact lenses, I have poor close-up vision. Another benefit of one rather than two contact lenses is that one eye is contact-lens-free for a long time. And I go through contact lenses half as fast. I wear lenses that last one month so I switch monthly which eye has the lens.

No optician told me this. No optician has even figured this out, as far as I know.

The most telling detail in Robin Hanson’s lecture about doctors was about a nurse assigned to measure hand-washing rates among surgeons at her hospital. After she measured the hand-washing rates, she — as ordered — correlated them with death rates. It turned out that the surgeon who washed his hands the least had the highest death rate. For reporting this — as she was ordered to — the nurse was fired. Robin learned this story from his wife, who was a friend of the ex-nurse.

I was very impressed by Robin’s lecture, which was both accessible and profound, and it was one reason that during my next encounter with a doctor I was more skeptical than most patients. As I blogged earlier:

I have a tiny hernia that I cannot detect but one day my primary-care doctor did. He referred me to Dr. [Eileen] Consorti, a general surgeon [in Berkeley]. She said I should have surgery for it. Why? I asked. Because it could get worse, she said. Eventually I asked: Why do you think itâ€™s better to have surgery than not? Surgery is dangerous. (Not to mention expensive and time-consuming.) She said there were clinical trials that showed this. Just use google, youâ€™ll find them, she said. I tried to find them. I looked and looked but failed to find any relevant evidence. My mom, who does medical searching for a living, was unable to find any completed clinical trials. One was in progress (which implied the answer to my question wasnâ€™t known). I spoke to Dr. Consorti again. I canâ€™t find any studies, I said, nor can my mom. Okay, weâ€™ll find some and copy them for you, she said, you can come by the office and pick them up. She sounded completely sure the studies existed. I waited. Nothing from Dr. Consortiâ€™s office. After a few weeks, I phoned her office and left a message. No reply. I waited a month, phoned again, and left another message. No reply.

Yesterday Dr. Consorti finally got back to me, by posting a comment:

Seth, While I am in the process of finding papers in the literature to satisfy your scientific curiosity on why this hernia should or should not be fixed I am additionally trying to care for around 30 new patients referred to me for their new cancer diagnosis in the last 3 months. This may or may not explain why I have not been motivated to answer your call regarding your ambivalence about fixing your hernia. Yes, it is small and runs the risk of incarceration at some time. I will call you once I clear my desk and do my own literature search. Thanks for the update. Eileen Consorti

Fair enough. She’s busy. And I am glad to have her reply and her view of the situation. On the other hand, I am pretty sure the studies she was so sure existed — that justified the surgery — don’t exist. To call my curiosity about whether the proposed surgery would do more good than harm “scientific” has a bit of truth: No doubt scientists understand better than others that you can test claims such as “you need this surgery”. But it isn’t “scientific” in the least to worry that a medical procedure will do more harm than good. Everyone, not just scientists, worries about that. Surgery is scary. Let’s set aside the death rate, which is low but non-zero. How many brain cells are killed by general anesthesia? Dr. Consorti doesn’t know, nor do I. The number is plausibly more than zero. I suspect a power-law distribution: Most instances of general anesthesia kill a small number, a small fraction kill a large number.

I pointed Robin to Dr. Consorti’s response. He replied:

I wonder if she even realizes that she in fact doesn’t know why you should get surgery.

What I know and Dr. Consorti, very reasonably, doesn’t know, is that my mom was a librarian at the UCSF medical library and has done a vast amount of medical-literature searching. If she can’t find any relevant studies, it is very likely they don’t exist. And my mom did find a study in progress, which, to repeat myself, shows that my question about cost versus benefit is a good one. Others had the same question and launched a study to answer it. Robin’s lecture helped me ask it. Thanks, Robin.

More. Robin’s version of the fired-nurse story is here. Thanks to Charles Williams.

The other shoe drops. A year ago Atul Gawande wrote in The New Yorker about the Apgar score, a low-tech measurement of newborn viability that led to vast improvements in obstetrics. That’s the “how to improve?” side of things. Now Gawande has written about something equally simple and powerful on the “here’s how to improve” side of medicine: the use of checklists to improve ICU treatment. The first article was called “The Score”; this one is called “The Checklist”.

Checklists are the idea of Peter Pronovost, an ICU doctor at Johns Hopkins Hospital. His first checklist, in 2001, was designed to prevent infections on tubes inserted into patients. Nurses made sure that doctors followed the checklist. It’s like the Ten Commandments: the top and bottom getting together to improve the behavior of people in the middle. Checklists involved the empowerment of nurses (bottom) by hospital administrators (top) to improve the performance of doctors (middle). No coincidence, I’m sure, that the Apgar score also involved female empowerment: Virginia Apgar was one of the first powerful women in medicine.

Pronovost told Gawande:

The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.

Not to mention a sick person’s perspective. I completely agree. Several years ago I heard an industrial designer give a talk to an interface design group. He said that new high-tech products go through three stages: (a) used only by gadgeteers and professional engineers (e.g., the first home computers); (b) used by experts (e.g., billing software for lawyers); and (c) mass market (e.g., cell phones). The discipline of engineering, he said, was good at designing for the first two stages but not the third.

The similarities suggest a common explanation. I think one reason goes back to Veblen: It is low status to do useful work. It may also have to do with male dominance of medical research and engineering. When balancing status versus usefulness, men may weigh status more highly.

More innovation in the delivery of medicine: house calls. No kidding. More about Peter Pronovost.

Ian Ayres’ interesting new book, Super Crunchers, has a chapter about expert prediction versus predictions from math models. Almost always, the math models do better than the experts. I learned about this in graduate school when I read stuff by Paul Meehl, a psychology professor who compared the predictions of clinicians and regression equations in the 1950s. The idea has gathered strength since then and now the persons in some jobs — such as loan officers — are required to follow an algorithm for making decisions. Their expertise is ignored. Obviously they no longer derive as much self-worth from their job, Ayres points out.

It’s like the beginning of agriculture. Lots has been written about the physical problems caused by the change to agriculture. Stature decreased, tooth decay increased, and so on. I’ve never read about the mental problems it must have caused. I can only speculate, of course, but here’s an possible example: Hunters derived self-worth from bringing meat to their families. Taking that away caused problems. (Watching Once Were Warriors, a terrific movie, should make this more plausible.)

I have never read anything about how to reintroduce into everyday jobs crucial mental elements that hunting had and farming lacked. Nutrition education, vitamin supplements, dietary fortification, and other nutrition programs push us toward a pre-agricultural diet, which was far more diverse and better balanced. There is no similar set of things that move us closer to pre-agricultural ways of making a living. My self-experimental research is all about the value stuff that ancient life had but modern life lacks — such as seeing lots of faces in the morning — but I have never figured out how to simulate elements of hunting, beyond being on one’s feet a lot.

Philip Weiss has written an excellent (as usual) article about Matt Drudge.

â€œMatt Drudge is just about the most powerful journalist in America,â€ said Pat Buchanan.

And he’s self-employed. He started way down:

This is an incredibly lonely kid, [said a friend]. He doesnâ€™t have a sister, his mother is in and out of hospitals [diagnosed with schizophrenia], the father was beside himself. In high school they treated him like shit. He was starting to lose his hair in high school; think what that does to a kid.

Amazon Vine rewards the siteâ€™s elite reviewers by giving them access to advance copies. According to a representative at Amazon, invitations have gone out to the siteâ€™s â€œtop reviewers,â€ deemed so by their review rankings, to become Vine Voices.

I once read about a Los Angeles catering business that wasn’t doing so well until they doubled their prices. This is the opposite of that.

When the Times switched from 10 books on the Hardcover [Best Sellers] list, they created a list of 15 Hardcover [Best Sellers] and a list of 5 Advice, How To and Miscellaneous [Best Sellers]. I wrote in and asked the editor why they only had 5 titles on this list and 15 on the others. She wrote back and said,

An article in this week’s BMJ about problems with clinical trials makes some of the points I made in a recent post. The article is based on a London conference held last week. In my post, I said the evaluation of the Shangri-La Diet going on at the SLD forums was in many ways better than a clinical trial.

At the conference, a speaker complained that

key groups of participants were often excluded from clinical studies

I pointed out that anyone could post at the SLD forums.

Doug Altman, professor of statistics in medicine at Oxford University, said that the presentation of statistical results of clinical trials “lacked transparency and precluded any further analysis.”

I said that the forums are more transparent.

Paul Glasziou, director of the Centre for Evidence Based Medicine at Oxford University, warned that many clinical trials described treatments that were difficult to replicate in normal clinical settings.

I said that the forums were more realistic — meaning that the treatments being tested were closer to what actually could happen.

“Religion is extremely important to the Tibetans,” says Wikipedia, but what does that mean? The Tibetan Buddhism entry is no help. Last night at dinner, however, I did learn what it means, at least in part. Tibetans spend a vast amount of time on religious observances — what the observer (Bryan Ng, a Berkeley engineer) called a “religion tax.” One example was a well-observed month-long annual religious festival. Another was a sensationally slow method of travel: Take a step or two, bow down, lie down on the ground, get up, take another step, bow down, and so on. This method is used to cover long distances, such as 20 miles or more. The extremely devout do this along highways.

The Chinese government wants to reduce the influence of religion, he said. Goods imported into Tibet from China via the new railway should increase commerce, for example. The power of the Chinese government makes it likely they will succeed.